Business strategy and healthcare

Category Archives: Universal health care

This past week frustration reigned in my office as I saw more cancer patients in one week than I have ever seen in a week. The big problem is that 2 of these patients with advanced disease have no health care insurance or their insurance that they have will not cover their surgery and further treatment. What to do? Wait for the Democrats running for President to give us Medicare for all??

People have to understand that one of the patients has a type of Medicare, however, her policy will not cover further treatment. Remember this for those of you who still believe that Medicare-for-all will solve all our problems.

The other fairly young patient with advanced cancer has a job but no healthcare insurance. But as a dedicated physician, I am going to operate on her in the office only charging her for supplies, which is probably what I will do for the “Medicare type of coverage.

But doctors can’t do this on a routine basis otherwise they couldn’t pay their bills, pay salaries to their staff and pay for their malpractice, healthcare insurance, pay their mortgage and put food on the table. What then? Less and fewer students would choose to go into medicine and care for us all.

And what happens when both of these patients need chemotherapy, radiation treatment, and or immunotherapy? Who is going to pay for their advanced care?

Harris Meyer reported that Healthcare-spending growth would raise at an annual average of 5.5% over the next decade, slightly faster than in the past few years, due to the aging of the baby boomers and healthcare price growth, the CMS Office of the Actuary projects.
Because that growth will exceed gross domestic product growth, the CMS predicts healthcare’s share of GDP will rise from 17.9% in 2017 to 19.4% in 2027, according to a report in Health Affairs released Wednesday. That’s close to the 19.7% the CMS actuary predicted in its last national health expenditure report a year ago.
Price increases are expected to account for nearly half the growth in personal healthcare spending from 2018 to 2027, with an increase in utilization and intensity of services accounting for an additional third of spending growth. The authors of the report said prices will increase by 2.8% for outpatient prescription drugs, 2.6% for hospitals, and 1.8% for physicians.
Overall outpatient drug spending is projected to increase by an average of 6.1% per year over the next decade, driven by increased utilization of new drugs and a modest increase in prices.
These spending trends could boost public support for policy proposals to regulate prices and boost competition for healthcare services and drugs. For instance, Democratic proposals for Medicare-for-all and public plan options would pay providers at Medicare prices, which generally are significantly lower than what private insurers pay.
“The cost trend will make it easier to fund a Medicare-for-all or public option plan, because the price differential between what Medicare and the private sector pay allows you to save money by paying Medicare rates,” said Gerald Anderson, a health policy professor at Johns Hopkins University.
But he and other experts say the projected spending growth over the next decade—which is sharply less than the 7.3% average annual growth from 1990 to 2007—may not be sufficiently alarming to spur politically thorny policy changes.
“There’s nothing here that ought to catch people by surprise,” said Gail Wilensky, a health economist at Project Hope who formerly served as Medicare administrator. “These (projections) offer no reason to celebrate, but they’re not unreasonable. And they’re probably higher than what we’ll actually see because there will be public or private-sector interventions of some sort.”
The projected 5.5% annual rate of growth from 2018 to 2017 would exceed the 5.3% rate during the Affordable Care Act coverage expansion period from 2014 to 2016, as well as the 3.9% growth rate during the Great Recession period of 2008-2013.

Medicare spending is expected to grow faster than Medicaid or private insurance spending due to the aging of the large Baby Boom population into the program, peaking this year. That will produce a 7.4% average annual Medicare spending growth rate over the next decade, compared with 5.5% for Medicaid and 4.8% for private insurance.
Medicaid expenditures will rise partly because of the new Medicaid expansions in Maine and Virginia and expected expansions in Idaho, Nebraska, and Utah.
Per-capita spending growth rates for Medicare, Medicaid, and private insurance are expected to be similar, at 4.7%, 4.1%, and 4.6%, respectively.
The 2017 congressional repeal of the Affordable Care Act’s penalty for not buying insurance, effective this year, will moderate national health spending growth by reducing private insurance enrollment, the report said. That repeal is projected to result in a net increase in the number of uninsured Americans by 1.3 million, to 31.2 million in 2019.
Still, 90.6% of Americans are expected to have coverage in 2019, down from 90.9% last year.
Overall price inflation for healthcare goods and services is expected to average 2.5% over the next decade, compared with 1.1% for 2014 to 2017. The CMS actuaries said prices will rise at least partly because of the weakening of restraining factors such as patient cost sharing, selective contracting by insurers, and improvements in productivity in physicians’ offices.
“Half the growth in spending will be price growth in spite of the fact that all these Baby Boomers are entering Medicare,” said Anderson, citing a famous 2003 Health Affairs article he co-authored. “It’s still the prices, stupid.”
Hospital spending will grow an average of 5.7% per year over the next decade, up from 5.1% in 2019, the actuaries said. Hospital prices will rise due to tighter labor markets and continued wage increases for hospital employees, including nurses.
Average annual spending growth for physician and clinical services is projected at 5.4% for the coming decade, as physician pay is driven up by the shortage of doctors to meet the needs of the aging population.
The economists in the Office of the Actuary who wrote the report acknowledged that their projections can be off for various reasons. For instance, last year they projected that healthcare spending in 2018 would increase by 5.3%. In their new report, they projected spending in 2018 grew only 4.4%.
Sean Keehan, one of the authors, said the 2018 projected spending growth was lowered in the new report due to slower-than-expected Medicaid enrollment and spending increases, smaller out-of-pocket spending hikes, and a more sluggish jump in prescription drug costs.
Anderson said the overall takeaway from the new CMS report is that the U.S. still hasn’t seriously bent the cost growth curve. “There’s no turndown,” he said. “We keep waiting for that turning point and the actuaries aren’t seeing that turning point at least through 2027.”

So, what do we do? Do we listen to the Democrats running for President and wrap our arms around Medicare for All or do we fix the Affordable Care Act or do we design another system?

Seattle Mayor signs Medicare-for-all resolution

Can the left’s ‘free-for-all’ Medicare work?

Fox News Brie Stimson noted that as the national health care debate rages on, Seattle has decided to support Medicare-for-all.

Last month, Seattle Rep. Pramila Jayapal introduced a bill, the Medicare for All Act of 2019, that would transition Americans to single-payer government-paid health care but does not explain how the government will pay for the plan.

This week, Seattle Mayor Jenny Durkan signed a City Council resolution in support of Jayapal’s bill, making Seattle the first city to back a Medicare-for-all bill.

“The U.S. has among the worst health outcomes in the developed world despite spending roughly 19 percent of our nation’s gross domestic product (GDP) on health care,” Seattle Council member. Lorena González said in a statement. “A single-payer system would improve health outcomes while lowering the cost of medical care and insurance.”

Editorial: Medicare for All isn’t the only way to go

Merrill Goozner reported that Healthcare providers and insurers are gearing up to oppose Medicare for All. No surprise there. Insurers can’t look kindly on legislation that would put them out of business. And providers are deathly afraid of losing the high rates from private insurers that cross-subsidize government-funded patients.

But at the same time as they mobilize to defeat M4A, shouldn’t they be outlining what they support?

Here’s what M4A advocates want to achieve. The first is universal coverage. Sadly, we’re again moving away from this basic human right due to actions by the Trump administration to undermine the Affordable Care Act. They want lower prices. Insurance premiums for employers and out-of-pocket expenses for individuals and families continue to rise faster than wages or economic growth.

Finally, they want an end to the frustration engendered by a system that erects roadblocks between physicians and patients. These range from insurer rules requiring prior authorization to seemingly arbitrary limits on what doctors can perform or prescribe.

Is M4A the only way to solve these problems? Of course not. When it comes to covering the uninsured, the ACA worked just fine. Massachusetts, the first state to implement an ACA-like program, had an uninsured rate of 2.5% in 2017. That’s not the 0% of most Organisation for Economic Co-operation and Development countries, but pretty close.

Politics are at the root of the ACA’s failures—not its Rube Goldberg design. The Supreme Court allowed states to opt out of the Medicaid expansion. And when the GOP-controlled Congress eliminated the individual mandate, key to making rates on the exchanges affordable, it reduced sign-ups, raised premiums and stopped the expansion dead in its tracks.

How about service prices? M4A would set prices at Medicare rates, which are well below private insurance rates but higher than Medicaid rates (both Medicaid and the Children’s Health Insurance Program are eliminated in Sen. Bernie Sanders’ M4A bill). But that’s not where most of its savings come from.

According to a sympathetic analysis from the University of Massachusetts at Amherst, half of M4A’s savings come from reducing provider and insurer administrative overhead. Another quarter comes from lower drug prices.

But these are one-time savings that will do little to stop the upward spiral of hospital and physician costs, which account for two-thirds of all spending. That’s where we get to the third issue supposedly addressed by M4A: the administrative hassles and limits imposed on obtaining care.

These aren’t eliminated by an expanded public system. They simply transfer the policing of waste, fraud, and abuse from private hands to public hands and change the motivation from padding profits to protecting taxpayers. In the past, Medicare has done a better job than private payers for one simple reason: it can impose price controls. Providers have responded by shifting much of the shortfall to their private-paying patients.

There are alternatives for achieving M4A’s goals. They include private companies offering exchange policies with well-defined coverage rules and strict limits on out-of-pocket costs; all-payer rate-setting or global budgets to slow the rate of price increases; merging Medicaid with Medicare (leaving long-term services and supports to the states), which would give private employers and families rate and tax relief; and establishing all-stakeholder oversight councils to develop medically appropriate utilization rules.

There’s more. The point is that in the post-Trump era, the U.S. will once again begin moving toward a healthcare system that is universal and affordable with high-quality care for everyone.

A multipayer approach could be like Germany and Switzerland, which rely on private insurers that are regulated to a much greater extent than currently exists in the U.S. Or it will be a single-payer system like Canada, Great Britain or France. Each delivers better results at a lower cost than the U.S.

I’m agnostic on which way to go. I’m still waiting for providers and insurers to articulate their vision.

Some ‘Cheaper’ Health Plans Have Surprising Costs

Julie Appleby reports that one health plan from a well-known insurer promises lower premiums — but warns that consumers may need to file their own claims and negotiate overcharges from hospitals and doctors. Another does away with annual deductibles — but requires policyholders to pay extra if they need certain surgeries and procedures.

Both are among the latest efforts in a seemingly endless quest by employers, consumers, and insurers for an elusive goal: less expensive coverage.

Premiums for many of these plans, which are sold outside the exchanges set up under Affordable Care Act, tend to be 15 to 30 percent lower than conventional offerings, but they put a larger burden on consumers to be savvy shoppers. The offerings tap into a common underlying frustration.

“Traditional health plans have not been able to stem high-cost increases, so people are tearing down the model and trying something different,” said Jeff Levin-Scherz, health management practice leader for benefits consultants Willis Towers Watson.

Not everyone is eligible for a subsidy to defray the cost of an ACA plan, and that has led some people to experiment with new ways to pay their medical expenses. Those experiments include short-term policies or alternatives like Christian-sharing ministries — which are not insurance at all, but rather cooperatives through which members pay one another’s bills.

Now some insurers — such as Blue Cross Blue Shield of North Carolina and a Minnesota startup called Bind Benefits, which is partnering with UnitedHealth Group — are coming up with their own novel offerings.

Insurers say the two new types of plans meet the ACA’s rules, although they interpret those rules in new ways. For example, the new policies avoid the federal law’s rule limiting consumers’ annual in-network limit on out-of-pocket costs. One policy manages that by having no network — patients are free to find providers on their own. And the other skirts the issue by calling additional charges “premiums.” Under ACA rules, premiums don’t count toward the out-of-pocket maximum.

But each plan could leave patients with huge costs in a system in which it is extremely difficult for a patient to be a smart shopper — in part because they have little negotiating power against big hospital systems and partly because the illness is often urgent and unanticipated.

If these alternative plans prompt doctors and hospitals to lower prices, “then that is worth taking a closer look,” says Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But if it’s simply another flavor of shifting more risk to employees, I don’t think in the long term, that’s going to bend the cost curve.”

Balancing freedom, control, and responsibility

The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40 percent above what Medicare would pay. The plan has no specific network of doctors and hospitals.

This approach “puts you in control to see the doctor you want,” the insurer says on its website. The plan is available to individuals who buy their own insurance and to small businesses with one to 50 employees. It’s aimed at consumers who cannot afford ACA plans, says Austin Vevurka, a spokesman for the insurer. The policies are not sold on the ACA’s insurance marketplace but can be purchased off-exchange from brokers.

With that freedom, however, consumers also have the responsibility to shop around for providers who will accept that amount of reimbursement for their services. Consumers who don’t shop — or can’t because their medical need is an emergency — may get “balance-billed” by providers who are unsatisfied with the flat amount the plan pays.

“There’s an incentive to comparison-shop to find a provider who accepts the benefit,” says Vevurka.

The cost of balance bills range widely but could be thousands of dollars in the case of hospital care. Consumer exposure to balance bills is not capped by the ACA for out-of-network care.

“There are a lot of people for whom a plan like this would present financial risk,” says Levin-Scherz.

In theory, though, paying 40 percent above Medicare rates could help drive down costs over time if enough providers accept those payments. That’s because hospitals currently get about double Medicare rates through their negotiations with insurers.

“It’s a bold move,” says Mark Hall, director of the health law and policy program at Wake Forest University in North Carolina. Still, he says, it’s “not an optimal way” because patients generally don’t want to negotiate with their doctor on prices.

“But it’s an innovative way to put matters into the hands of patients as consumers,” Hall says. “Let them deal directly with providers who insist on charging more than 140 percent of Medicare.”

Blue Cross spokesman Vevurka says My Choice has telephone advisers to help patients find providers and offer tips on how to negotiate a balance bill. He would not disclose enrollment numbers for My Choice, which launched Jan. 1, nor would he say how many providers have indicated they will accept the plan’s payment levels.

Still, the idea — based on what is sometimes called “reference pricing” or “Medicare plus” — is gaining attention. Under that method, hospitals are paid a rate based on what Medicare pays, plus an additional percentage to allow them a modest profit.

North Carolina’s state treasurer, for example, hopes to put state workers into such a pricing plan by next year, offering to pay 177 percent of Medicare. The plan has ignited a firestorm of opposition from hospitals in the state.

Montana recently got its hospitals to agree to such a plan for state workers, paying 234 percent of Medicare, on average.

Partly because of concerns about balance-billing, employers aren’t rushing to buy into Medicare-plus pricing just yet, says Jeff Long, a health care actuary at Lockton Companies, a benefits consultancy.

Wider adoption, however, could spell its end.

Hospitals might agree to participate in a few such programs, but “if there’s more take up on this, I see hospitals possibly starting to fight back,” Long says.

What about the bind?

Minnesota startup Bind Benefits eliminates annual deductibles in its “on-demand” plans sold to employers that are opting to self-insure their workers’ health costs. Rather than deductibles, patients pay flat-dollar copayments for a core set of medical services, from doctor visits to prescription drugs.

In some ways, it’s simpler: There is no need to spend through the deductible before coverage kicks in or wonder what 20 percent of the cost of a doctor visit or surgery would be.

But not all services are included. Does this sound familiar? As I started this post with my examples…ladies and gentlemen, we have a problem!!

Patients who discover during the year that they need any of about 30 common procedures outlined in the plan, including several types of back surgery, knee arthroscopy or coronary artery bypass, must “add in” coverage, spread out over time in deductions from their paychecks.

“People are used to that concept, to buy what they need,” said Bind CEO Tony Miller. “When I need more, I buy more.”

According to a company spokeswoman, the add-in costs vary by market, procedure, and provider. On the lower end, the cost for tonsillectomy and adenoidectomy ranges from $900 to $3,000, while lumbar spine fusion could range from $5,000 to $10,000.

To set those additional premiums, Bind analyzes how much doctors and facilities are paid, along with some quality measures from several sources, including UnitedHealth. The add-in premiums paid by patients vary depending on whether they choose lower-cost providers or more expensive ones.

The ACA’s 2019 out-of-pocket maximums — $7,900 for an individual or $15,800 for a family — don’t include premium costs.

The Cumberland School District in Wisconsin switched from a traditional plan, which it purchased from an insurer for about $1.7 million last year, to Bind. Six months in, according to the school district’s superintendent, Barry Rose, the plan is working well.

Right off the bat, he says, the district saved about $200,000. More savings could come over the year if workers choose lower-cost alternatives for the “add-in” services.

“They can become better consumers because they can see exactly what they’re paying for care,” Rose says.

Levin-Scherz at Willis Towers says the idea behind Bind is intriguing but raises some concerns for employers.

What happens, he asks, if a worker has an add-in surgery, owes several thousand dollars, and then changes jobs before paying all the premiums for that add-in coverage? “Will the employee be sent a bill after leaving?” he wonders.

A Bind spokeswoman says the former employee would not pay the remaining premiums in that case. Instead, the employer would be stuck with the bill.

Next week back to finding a way to improve the Affordable Care Act/ Obamacare.

Here is my question for the week, with all this talk of Medicare for All what happened to Obamacare the pride of the Democratic Party and the Golden Trophy of President Obama?

This was and still is a great idea to provide health care for many/all and was designed by very smart people. The only big problem was how to pay for it and therefore how to make it sustainable, especially after removing the Individual Mandate. Why then Medicare for All with all of its own problems? Susannah Luthi wrote that the Centrist House Democrats on Wednesday launched a push to revive Obamacare stabilization talks, two hours after their progressive wing unveiled new Medicare for All legislation.

But Now Some of the Moderate Democrats revive talks to fund CSRs, reinsurance

The 101-strong New Democrat Coalition wants to fund reinsurance and cost-sharing reduction payments in a package that closely resembles the deal struck last Congress by Senate health committee leaders Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.).

That bill, known colloquially as Alexander-Murray, fell apart at the last minute following a GOP-Democratic dispute over including anti-abortion language.

“Well, we would call it Schrader-Bera-Kuster,” joked Rep. Kurt Schrader (D-Ore.), one of the co-chairs of the coalition’s healthcare task force as he referred to fellow co-chairs Reps. Ami Bera (D-Calif.) and Annie Kuster (D-N.H.).

He said the group wants to take another run at it, as this is a “different Congress, with different makeup,” and voters gave Congress a mandate to make the individual market more affordable.

To prod leadership into action, the group sent a letter urging prompt committee action to key committee leaders—Frank Pallone (D-N.J.) of Energy and Commerce, Chair Richard Neal (D-Mass.) of Ways and Means, and Bobby Scott (D-Va.) of Education and Labor.

“Building upon your work and the work of the New Democrat Coalition last Congress, we urge your committees to deliver on the promises made to our constituents by prioritizing strengthening the ACA and continuing the path toward universal affordable coverage,” the group wrote.

The group hopes numbers are on their side. It’s now the largest ideological caucus in Congress and owes its swelling ranks to the 40 Democratic freshmen who swept into office largely with the ACA on their platform.

The coalition announced its healthcare policy wish list two hours after progressive Democrats’ 70-minute press conference unveiling the new Medicare for All or single payer legislation.

Coalition members downplayed their role as opposing single payer—highlighting instead the pragmatism of lowering ACA individual market premiums as action Congress can take immediately for people who remain unsubsidized.

They also said they want to discuss public options, such as a policy to allow people to buy into Medicare or Medicaid.

Democratic leaders have pushed support for the ACA as a key part of their agenda, but proposals so far this Congress haven’t included funding for CSRs—whose cut-off led to the silver-loading that boosts premiums for people who can’t get subsidies—or reinsurance.

The Pallone-Neal-Scott proposal from last year includes reinsurance and CSRs, but enthusiasm for funding CSRs has waned since last year. Liberal advocates like the fact that the CSR cut-off led to bigger subsidies for low-income people.

And while insurers hope stabilization talks resurface, their profitability on the exchanges is soaring.

On Wednesday, Pallone told an audience at an Atlantic Live event that he’s most interested in growing the subsidies—increasing the pool of people who qualify for them and raising what’s available for people who currently receive them.

“It’s clear now that people at the higher income level, who were not eligible for those subsidies before, that we need to raise that, for people with a higher income, because there are people now making over $85, $90k a year who don’t get any subsidy,” Pallone said Wednesday morning. “In a place like New Jersey, that’s not a lot of income for a family of four.”

He also confirmed that the House will push back against the Trump administration’s expansion of short-term, limited duration plans.

Pallone was pressed on the cost problem: that an increase in subsidies puts the government on the hook for most of the high premiums, he pointed to his proposal to set up a reinsurance pool.

On whether Congress could overcome last year’s dispute over abortion language, Schrader was optimistic.

However, a Republican aide for the Senate health committee responded by referring to a comment made to Modern Healthcare last week.

“The only way Congress could pass an appropriation for CSRs is if Democrats reverse course and agree to apply the Hyde Amendment which applies to all other healthcare appropriations,” the staffer said.

Dems hit GOP on health care with additional ObamaCare lawsuit vote

At the beginning of January, Jessie Hellmann reported that in the first week of this year the House passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

And Now the House Democrats Decry ‘Junk Plans’ and are introducing bills to reverse Trump-inflicted ACA “sabotage”

Shannon Firth noted that the Democrats blasted attempts by the Trump administration to “sabotage” the Affordable Care Act during a House Energy & Commerce Health Subcommittee hearing on Wednesday.

“We’re inviting people back into a world with mirrors and trap doors, which was exactly the place we wanted to get away from when we passed the ACA,” said Rep. John Sarbanes (D-Md.), who called on his colleagues to “push back against these junk plans.”

House Democrats introduced four bills to roll back administration efforts to loosen or circumvent the ACA’s insurance requirements. In the very unlikely event that they pass the Republican-controlled Senate and gain the president’s signature, they would:

Require all short-term health plans to include a warning explicitly stating which benefits are included and which aren’t

Restore marketing and outreach funding for ACA exchanges

Rescind a regulation that extended the allowable duration of short-term plans (including renewals) to just under 3 years

Cancel the administration’s new guidance around 1332 waivers, which relaxed certain “guard rails”

Republicans complained that ACA plans are unaffordable for middle-income Americans who don’t receive subsidies, and argued that the Trump administration’s actions allow those same Americans more options for cheaper health plans.

“They’re really trying to give consumers new options, particularly those who were shut out of the market because of costs,” said Grace-Marie Turner, a witness at the hearing and president of the Galen Institute, a conservative think tank, in defense of the administration.

Republicans also pushed back on criticism of the administration’s 1332 waiver guidance, saying Democrats were denying states the right to innovate their programs and instead of trying to impose the will of Washington.

Turner stressed that states are better positioned to regulate their own local health insurance markets.

Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, said that none of the bills being discussed would increase the availability of “reasonably priced plans.”

Are Short-Term Plans Junk?

Much of Wednesday’s discussion focused on short-term plans, which are cheaper than ACA exchange plans but offer a shrunken set of benefits.

In August, the Trump administration issued a final rule extending the duration of these plans for just under 12 months and made plans eligible for renewals for nearly 3 years. Previously, the plans were available for just under 3 months at a maximum.

Rep. Kathy Castor (D-Fla.), who introduced a bill to rescind the short-term plan rule, said she’s worried “the public is being snookered here.”

“Maybe you were healthy when you signed up. Then, something happens — you have a big medical claim. It triggers an alarm and [the insurers] go back and look at your application, and pull all your medical records again and go, ‘Oh, you should have told us about this,'” she told MedPage Today after the hearing.

Even in cases where a patient was not diagnosed with an illness prior to enrollment, insurers find ways to justify cancellation, she said.

Rep. Nanette Barragán (D-Calif.) offered one example, a Chicago businessman who was encouraged to buy a short-term plan by a broker even after disclosing symptoms of serious back pain. After he enrolled, the businessman was diagnosed with non-Hodgkin lymphoma. Insurers then reviewed his medical records and determined that the businessman’s cancer was a pre-existing condition because he had visited a chiropractor in the past, leaving him with over $800,000 in medical bills after 6 months, Barragán said.

“You would never expect your cancer treatment to be denied because you’ve had bad back pain,” Keith said. “That’s something that, I think, disclosures can’t fix.”

Jessica Altman, Pennsylvania Insurance Department commissioner, pointed out that short-term plans may not cover ACA-defined “essential health benefits.” She cited a study showing that less than 60% cover mental health, only about one-third cover treatment for substance use disorder or prescription drugs, and none included maternity benefits.

Altman also noted that short-term plans aren’t required to abide by the ACA’s medical loss ratio requirements. The two largest short-term plan vendors, which control 80% of the market, spend less than half of each premium dollar on “actual medical care,” she said.

But Turner said short-term plans are meant to serve as “bridge plans” for individuals such as early retirees, people in the gig economy, and young entrepreneurs starting a business, who would convert before long to more comprehensive coverage. Turner also emphasized the plans’ affordability — with premiums less than half of what an ACA plan would cost — and stressed that consumers understand the plans aren’t permanent.

Rep. Richard Hudson (R-N.C.) pointed out that states are allowed to impose limits on short-term plans or ban them altogether.

“I think it’s important to note that we’re not forcing anyone into this. We’re giving flexibility to the states,” he said.

He suggested bringing in witnesses from states where plans are available to learn their true impact.

New Waiver Guidance

Another bill, explored at the hearing, would revoke the administration’s changes to 1332 waivers, which loosened standards for what qualifies as healthcare coverage. The administration’s waiver also allows ACA subsidies to be spent on short-term plans.

Rep. Frank Pallone (D-N.J.), who chairs the full Energy & Commerce Committee, said the changes “turn the statute on its head,” exceeding the administration’s authority and “contrary to congressional intent.”

Keith agreed. She said the guidance was inconsistent with the statute itself. Instead of improving access to healthcare, the guidance “undermines” it. In particular, subsidizing short-term health plans “flies in the face of 1332,” she said.

Several Republicans, including Rep. Greg Walden (R-Ore.), ranking member for the full committee, highlighted the successful implementation of reinsurance programs in states such as Alaska, Minnesota, Oregon, and others, claiming that Democrats oppose state innovation.

Keith clarified that the reinsurance programs were approved under the 1332 rules as written by the previous administration, without the Trump administration’s changes.

Any waivers approved under the Trump administration’s new guidance would likely trigger a lawsuit, she said. As for short-term health plans, several patient advocacy groups have already filed a lawsuit targeting the administration’s new guidance for those plans.

So, I am not going to pursue this issue anymore because I want all of us to consider my first question-Why are Bernie Saunders and most of the multiple Democrat candidates running for President in 2020 touting Medicare for All instead of coming up with fixes for the Affordable Care Act/ Obamacare?

Let us discuss possible fixes to Obamacare next week.

And to a lighter side:

You can now buy an actual hospital room on Amazon

Amazon is increasingly moving into the business of selling supplies to hospitals.

Now, that includes “smart” hospital rooms that can be purchased on its marketplace as of Thursday.

The units are targeted to hospitals and are made by a company called EIR Healthcare.

MedModular

You can buy almost everything on Amazon. And that includes, as of Thursday, a “smart” hospital room in a box.

A New York-based company called EIR Healthcare is now selling units of its hospital room, dubbed MedModular, for $814 a square foot on Amazon.com, which the company claims are more affordable than traditional construction. The design is customizable but all the rooms come with a bathroom and a bed.

These rooms don’t come cheap at $285,000 per unit, but they are targeted to business buyers that are increasingly flocking to Amazon.

So who would buy the units?

“We’re targeting hospitals and health systems,” said Grant Geiger, CEO of EIR Healthcare, the company selling the units. “There’s a trend towards bringing more transparency in the health care space,” he added.

Geiger said he’s currently seeing an uptick in interest from hospitals in using the units for things like simulation labs, or urgent care facilities.

Geiger has also considered looking into potential customers in the military.

But hospital administrators are an obvious place to start, he said, as Amazon is already selling them medical supplies ranging from bedpans to syringes. Previously, large hospital systems would buy everything through group purchasing organizations, or GPOs, which provided discounts but also a lack of transparency around costs.

MedModular

Now, Amazon is looking to carve out its own slice of that lucrative business with its own growing portfolio of medical supplies.

Geiger said he talked to that group for months before he got permission to sell his units on Amazon’s marketplace. He also needed the company’s approval to ship and deliver the product, which involves transporting the units in giant shipping containers down the freeway.

It was an interesting week on so many levels. I guess that we don’t have to worry about another government shut down…. until next September but now Congress, the Senate and the President will fight and get nothing done… Probably not even getting the full wall.

Can any progress be made on health care if we have all this anger, incivility and progressive socialism?!? Let’s have progress in health care and vows to work for a better future!

News Editor of MedPage, Joyce Frieden remarked that Congress needs to do a better job of funding public health priorities and improving the healthcare system, a group of six physician organizations told members of Congress.

Presidents of six physician organizations — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association — visited members of Congress as a group here Wednesday to get their message across. The American Medical Association, whose annual Washington advocacy conference takes place here next week, did not participate.

The physician organizations had a series of principles that they wanted to emphasize during their Capitol Hill visits, including:

Helping people maintain their insurance coverage

Protecting patient-centered insurance reforms

Stabilizing the insurance market

Improving the healthcare financing system

Addressing high prescription drug prices

The group also released a list of proposed 2020 appropriations for various federal healthcare agencies, including:

$8.75 billion for the Health Resources and Services Administration

$7.8 billion for the CDC

$460 million for the Agency for Healthcare Research and Quality

$41.6 billion for the National Institutes of Health

$3.7 billion for the Centers for Medicare & Medicaid Services

One of the group’s specific principles revolves around Medicaid funding. “Policymakers should not make changes to federal Medicaid funding that would erode benefits, eligibility, or coverage compared to current law,” the group said in its priorities statement.

This would include programs like the work requirements recently approved in Arkansas and other states; the Kaiser Family Foundation reported in January that more than 18,000 Arkansans have been dropped from the Medicaid rolls for failing to meet the work requirements there.

“Our group is very, very supportive of innovation,” said Ana Maria López, MD, MPH, president of the American College of Physicians, at a breakfast briefing here with reporters. “We welcome testing and evaluation, but we have a very strong tenet that any effort should first do no harm, so any proposed changes should increase — not decrease — the number of people who are insured. Anything that decreases access we should not support.”

That includes work requirements, said John Cullen, MD, president of the American Academy of Family Physicians. “When waivers are used in ways that are trying to get people off of the Medicaid rolls, I think that’s a problem,” he said. “What you want to do is increase coverage.”

Lydia Jeffries, MD, a member of the government affairs committee of the American College of Obstetricians and Gynecologists, agreed. “We support voluntary efforts to increase jobs in the Medicaid population, but we strongly feel that mandatory efforts are against our principal tenets of increasing coverage.”

More $$ for Gun Violence Research

Gun violence research is another focus for the group, which is seeking $50 million in new CDC funding to study firearm-related morbidity and mortality prevention. Kyle Yasuda, MD, president of the American Academy of Pediatrics, explained that gun research stopped in 1997 after the passage of the so-called Dickey Amendment, which prevented the CDC from doing any “gun control advocacy” — that is, accepting for publication obviously biased articles and rejecting any articles that found any positive benefits to gun ownership. Although the amendment didn’t ban the research per se, the CDC chose to comply with it by just avoiding any gun violence research altogether.

Recently, however, Health and Human Services Secretary Alex Azar and CDC Director Robert Redfield, MD, “have provided assurances that the language in the Dickey Amendment would allow for [this] research,” said Yasuda. “We didn’t have research to guide us and that’s what we need to go back to.”

The research is important, said Altha Stewart, MD, president of the American Psychiatric Association, because “in addition to the physical consequences related to gun violence, there’s a long-term psychological impact on everyone involved — both the people who are hurt and the people who witness that hurt. It’s a set of concentric circles that emerges when we talk about the psychological effects of trauma. We often think of [these people] as outliers, but for many people, we work with, this has become all too common in their lives.

“This is definitely our lane as physicians and I’m glad we’re in it,” she said, referring to a popular hashtag on the topic.

Yasuda said the effects of gun violence are nothing new to him because he spent half his career as a trauma surgeon in Seattle. “It’s not just the long-term effect on kids, it is the next generation of kids … It’s the impact on future generations that this exposure to gun violence has on our society, and we just have to stop it.”

The high cost of prescription drugs also needs to be addressed, López said. “We see this every day; people come in and have a list of medications, and you look and see when they were refilled, and see that the refill times are not exactly right … People will say, ‘I can afford to take these two meds on a daily basis, these I have to take once a week’ … They make a plan. [They say] ‘I can fill my meds or I can pay my rent.’ People are making these sorts of choices, and as physicians, it’s our job to advocate for their health.”

One thing the group is staying away from is endorsing a specific health reform plan. “We’re agnostic as far as what a plan looks like, but it has to follow the principles we’ve outlined on consumer protection, coverage, and benefits,” said Cullen. “As far as a specific plan, we have not decided on that.”

Also, Politicians Need To Change The Conversation On How To Fix Health Care

Discussions about Medicare for all, free market care, and Obamacare address one issue – how we pay for health care. The public is tired of these political sound bites and doesn’t have faith in either public or private payment systems to fix their health care woes. Changing the payer system isn’t going to fix the real problem of the underlying cost of care and how it is delivered.

The current system is rotting from the inside. Fee for service payment started the trend with rewarding health care providers for the amount of care they deliver. Through the decades, health care organizations learned how to manipulate the system to maximize profit. Remember, at no time has an insurer lost money. They just increase premiums and decrease reimbursements to health care facilities and caregivers and constrict their coverage. Insurers retaliated by creating more hoops to jump through to get services covered. This includes both Medicare and private insurance.

Who is left to deal with the quagmire? The patients. Additionally, the health care professionals who originally entered their profession to take care of people became burned out minions of the health care machine. Now we are left with an expensive, fragmented health care system that costs three times more than the average costs of other developed countries and has much poorer health outcomes.

Our country needs a fresh conversation on how to fix our health care system. The politicians who can simplify health care delivery and provide a plan to help the most people at a reasonable cost will win the day. There are straightforward fixes to the problem.

About 75% of the population needs only primary care. Early hypertension, diabetes, and other common chronic issues can be easily cared for by a good primary care system. This will reduce the progression of a disease and reduce costs down the line. Unfortunately, the fee for service system has decimated our primary care workforce through turf wars and payment disparities with specialty care and we now have a severe primary care shortage. Patients often end up with multiple specialists which increases cost, provides unsafe and fragmented care, and decreases patient productivity.

Insurance is meant to cover only high cost or rare events. Primary care is inexpensive and is needed regularly, so it is not insurable. We pay insurance companies 25% in overhead for the privilege of covering our primary care expenses. Plus, patients and their doctors often must fight insurance companies to get services covered. The lost productivity for patients and care providers is immeasurable.

In a previous article, the author shared the proposal of creating a nationalized network of community health centers to provide free primary care, dental care, and mental health care to everyone in this country.

Community health centers currently provide these services for an average cost of less than $1,000 per person per year. By providing this care free to all, we can remove primary care from insurance coverage, which would reduce the cost of health insurance premiums.

Free primary care would improve population health, which will subsequently reduce the cost of specialty care and further reduce premiums.

Community health centers can serve as treatment centers for addiction, such as our current opioid crisis, and serve as centers of preparedness for epidemic and bioterrorist events.

People who do not want to access a community health center can pay for primary care through direct primary care providers.

This idea is not unprecedented – Spain enacted a nationwide system of community health centers in the 1980s. Health care measures, patient satisfaction, and costs improved significantly.

By providing a free base of primary care, dental care, and mental health care to everyone in this country, we can improve health, reduce costs, and improve productivity while we work toward fixing our health care payment system.

Current Community Health Centers

Community health centers currently serve approximately 25 million low-income patients although they have the structural capacity to serve many more. This historical perspective of serving low-income individuals may be a barrier to acceptance in the wider population. In fact, when discussing this proposal with a number of health economists and policy people, many felt the current variability in the quality of care would discourage use of community health centers in all but a low-income population. Proper funding, a culture of care and accountability, and the creation of a high functioning state of the art facilities would address this concern.

There are currently a number of community health centers offering innovative care, including dental and mental health care. Some centers use group care and community health workers to deliver care to their communities. Many have programs making a serious dent in fighting the opioid epidemic. Taking the best of these high functioning clinics and creating a prototype clinic to serve every community in our nation is the first step in fixing our health care system

The Prototype Community Health Center – Delivery of Care

Community health centers will be built around the patient’s needs. Each clinic should have:

Extended and weekend hours to deliver both acute and routine primary care, dental care, and mental health care. This includes reproductive and pediatric care.

Home visits using community health workers and telemedicine to reach remote areas, homebound, and vulnerable populations such as the elderly.

A pharmacy that provides generic medications used for common acute and chronic illnesses. Medication will be issued during the patient’s visit.

There will be no patient billing. Centers will be paid globally based on the population they serve.

The standard of care will be evidence-based for problems that have evidence-based research available. If patients desire care that is not evidence based, they can access it outside the community health system and pay for that care directly. For problems that do not have evidence-based research, basic standards of care will apply.

It will be very important that both providers and patients understand exactly what services will be delivered. By setting clear expectations and boundaries, efficiency can be maintained and manipulation of the system can be minimized.

The Prototype Community Health Center – Staffing

The clinics would be federally staffed and funded. Health care providers and other employees will receive competitive salary and benefits. To attract primary care providers, school loan repayment plans can be part of the compensation package.

The “culture” of community health centers must be codified and will be an additional attraction for potential employees. A positive culture focused on keeping patients AND staff healthy and happy, open communication, non-defensive problem solving, and an attitude of creating success should be the standard. Bonuses should be based on the quality of care delivery and participation in maintaining good culture.

One nationalized medical record system will be used for all community health centers. The medical records will be built solely for patient care. Clinical decision support systems can be utilized to guide health care providers in standards of diagnosis and treatment, including when to refer outside the system.

Through the use of telemedicine, basic consultation with specialists can be provided but specialists will consult with the primary care physicians directly. One specialist can serve many clinics. For example, if a patient has a rash that is difficult to diagnose, the primary care doctor will take a picture and send it to the dermatologist for assistance.

For services beyond primary care and basic specialty consultation, insurance will still apply. The premiums for these policies will be much lower because primary care will be excluded from coverage.

How to get “there” from “here”

Think Starbucks – after the development of the prototype design based on currently successful models, with proper funding, centers can be built quickly. Attracting primary care providers, dentists, and mental health care providers will be key to success.

Basic services can be instituted first – immunizations, preventive care, reproductive care, and chronic disease management programs can be standardized and easily delivered by ancillary care providers and community health workers. Epidemic and bioterrorist management modules can be provided to each center. As the primary care workforce is rebuilt, further services can be added such as acute care visits, basic specialty consultations, and expanded dental and mental health care.

With the implementation of this primary care system, payment reform can be addressed. Less expensive policies can immediately be offered that exclude primary care. Ideally, we will move toward a value-based payment system for specialty care. The decision on Medicare for all, a totally private payer system, or a public and private option can be made. Thankfully, during the political discourse, 75% of the population will have their needs fully met and our country will start down the road to better health.

Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away.

The Twitter account for Fox & Friends this week ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result.

At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Should we all be even concerned about any of these health care problems if AOC is right and the world ends in 12 years? Good young Ocasio Cortez, if she only had ahold on reality!! Her ideas will cost us all trillions of dollars, tax dollars, which we will all pay! Are we all ready for the Green Revolution?

Actually, I thought that President Trump did a good job even being conciliatory in his State of the Union speech even covering various aspects of healthcare. Joyce Frieden the News Editor of MedPage stated that Healthcare played a major part in Tuesday’s State of the Union address, with President Trump covering a wide variety of health-related topics.

Only a few minutes into the speech, the president foreshadowed some of his healthcare themes. “Many of us have campaigned the same core promises to defend American jobs and … to reduce the price of healthcare and prescription drugs,” Trump said. “It’s a new opportunity in American politics if only we have the courage together to seize it.”

A few minutes later, he touted some of his administration’s actions so far. “We eliminated the very unpopular Obamacare individual mandate penalty,” Trump said. “And to give critically ill patients access to lifesaving cures, we passed — very importantly — the right to try.”

Drug Prices a Major Player

The subject of drug prices occupied a fair amount of time. “The next major priority for me, and for all of us, is to lower the cost of healthcare and prescription drugs and to protect patients with preexisting conditions,” he said. “Already, as a result of my administration’s efforts in 2018, drug prices experienced their single largest decline in 46 years. But we must do more. It’s unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place.”

“This is wrong; this is unfair, and together we will stop it, and we’ll stop it fast,” he said. “I am asking the Congress to pass legislation that finally takes on the problem of global freeloading and delivers fairness and price transparency for American patients, finally.”

He then turned to several other health topics. “We should also require drug companies, insurance companies, and hospitals to disclose real prices, to foster competition, and bring costs way down,” Trump said. He quickly moved on to the AIDS epidemic. “In recent years we’ve made remarkable progress in the fight against HIV and AIDS. Scientific breakthroughs have brought a once distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.”

“We have made incredible strides, incredible,” he added to applause from members of Congress on both sides of the aisle. “Together we will defeat AIDS in America and beyond.”

Childhood Cancer Initiative

Although the remarks on HIV had been expected, the president also announced another health initiative that wasn’t as well-known: a fight against childhood cancer. “Tonight I’m also asking you to join me in another fight all Americans can get behind — the fight against childhood cancer,” he said, pointing out a guest of First Lady Melania Trump: Grace Eline, a 10-year-old girl with brain cancer.

“Every birthday, since she was 4, Grace asked her friends to donate to St. Jude’s Children’s Hospital,” Trump said. “She did not know that one day she might be a patient herself [but] that’s what happened. Last year Grace was diagnosed with brain cancer. Immediately she began radiation treatment, and at the same time she rallied her community and raised more than $40,000 for the fight against cancer.”

“Many childhood cancers have not seen new therapies in decades,” he said. “My budget will ask Congress for $500 million over the next 10 years to fund this critical life-saving research.”

These health initiatives met with mixed reactions. “President Trump is taking a bold step to design an innovative program and strategy, and commit new resources, to end HIV in the United States … Under the President’s proposal, the number of new infections can eventually be reduced to zero,” Carl Schmid, deputy executive director of The AIDS Institute, said in a statement. Michael Ruppal, the institute’s executive director, added, “While we might have policy differences with the president and his administration, this initiative if properly implemented and resourced, can go down in history as one of the most significant achievements of his presidency.”

But the Democratic National Committee (DNC) wasn’t quite so enthusiastic; it sent an email calling the goal of ending HIV by 2030 “notable” but added, “The Trump administration has consistently undermined advancements in HIV/AIDS research, attacked people living with HIV/AIDS, and sabotaged access to quality healthcare at every opportunity.” Among other things, the administration redirected money from the Ryan White HIV/AIDS Program to help fund the separation of immigrant families, and proposed cutting global HIV/AIDS funding by over $1 billion, which could cause 300,000 deaths per year, the DNC said.

Abortion in the Spotlight

As for the childhood cancer initiative, “$500 million over 10 years to solve childhood cancer is … not a lot,” one Bloomberg reporter tweeted. However, Gail Wilensky, Ph.D., a senior fellow at Project HOPE, in Bethesda, Maryland, pointed out that this amount ” is in addition to the National Institutes of Health budget [for cancer] … A lot of money is going to cancer anyway [already] and the National Cancer Institute been one of the more protected parts of government, so it’s not like they have a big deficit to make up.”

Overall, “it was a surprisingly good speech,” said Wilensky, who was the administrator of the Centers for Medicare & Medicaid Services under President George H.W. Bush. “It covered a lot of areas, and there were a number of issues that were very hard not to applaud … I thought he did a pretty admirable job of forcing applause and a sense of togetherness by the country, talking about compromise and the common good.”

The president also touched on a more controversial area of healthcare: abortion. He referred to a recent abortion bill that passed in New York State and another that failed in Virginia — both of which dealt with abortion late in pregnancy — adding, “I’m asking Congress to pass legislation to prohibit late-term abortion of children who can feel pain in a mother’s womb. Let us work together to build a culture that cherishes innocent life.”

That appeal to the anti-abortion movement “is a position that Republicans have taken in the past, which is the importance of life right after birth and life right before birth,” said Wilensky. Abortion later in pregnancy “is an area that tends to engender a more unified response than most others, even for people who are ambivalent or more supportive of abortion rights. Very late-term abortion makes people uncomfortable … It’s easy to understand why people get uneasy.”

“Already, the biggest move the Trump administration has made to control health care costs and access has been on the regulatory front,” said Bob Laszewski, founder of Health Policy and Strategy Associates, an Alexandria, Virginia, consulting firm, citing the announcement of proposed regulations to end drug rebates under Medicare and Medicaid kickback rules and rules for short-term health plans. “I take it from Trump’s remarks that they will continue with this regulatory approach instead of waiting for any bipartisanship in the Congress,” he said.

“The only area there now seems to be a hint of bipartisanship is over the issue of drug prices being too high,” Laszewski added. “It was clear from Trump’s remarks, and the Democrats’ positive response on this one issue, that this could become an area for cooperation.”

No Large-Scale Reforms Offered

Rosemarie Day, a healthcare consultant in Somerville, Massachusetts, said in an email that the president “certainly did not propose any large-scale reforms to the healthcare system during the speech, and he was short on specifics for most of it. According to a recent Kaiser Family Foundation poll, health care is the number one issue among voters so this may appear to some as a missed opportunity. It’s increasingly looking like Republicans are leaving the big health care reform ideas to the Democratic presidential candidates.”

The ideas he did propose “were mostly noncontroversial and somewhat vague,” Day continued. “The more interesting proposal was lowering the cost of healthcare and drugs, which is a high priority for consumers. The way he discussed going about it was by requiring drug companies, insurance companies, and hospitals to disclose real prices. This raises many questions, such as what does a ‘real’ price mean? … This will be an interesting area to watch, since ‘real prices’ are currently closely held secrets, and a legal requirement to disclose them would constitute a significant change from the status quo.”

In the Democratic response to the speech, Stacey Abrams, a Democrat who ran unsuccessfully last year for governor of Georgia, lashed out against enemies of Obamacare. “Rather than suing to dismantle the Affordable Care Act as Republican attorneys general have, our leaders must protect the progress we’ve made and commit to expanding healthcare and lowering costs for everyone,” said Abrams, the first black woman to deliver the rebuttal to a State of the Union address.

She also spoke of her personal struggle with healthcare costs for her family. “My father has battled prostate cancer for years. To help cover the costs, I found myself sinking deeper into debt because, while you can defer some payments, you can’t defer cancer treatment. In this great nation, Americans are skipping blood pressure pills, forced to choose between buying medicine and paying rent.”

She also pushed back against state governors and legislators who continue their resistance to Medicaid expansion. “In 14 states, including my home state, where a majority want it, our leaders refused to expand Medicaid which could save rural hospitals, save economies and save lives.”

With Dems now in charge, repeal-and-replace no longer on the table!

Former Rep. John Dingell Left An Enduring Health Care Legacy

If anyone is interested in healthcare and its history here in the U.S. one must include the legacy of former Rep. John Dingell, the Michigan Democrat who holds the record as the longest-serving member of the U.S. House, died Thursday night in Michigan. Julie Rovner reviewed his history last week after his death. He was 92.

And while his name was not familiar to many, his impact on the nation, and on health care, in particular, was immense.

For more than 16 years Dingell led the powerful House Energy and Commerce Committee, which is responsible for overseeing the Medicare and Medicaid programs, the U.S. Public Health Service, the Food and Drug Administration and the National Institutes of Health.

Dingell served in the House for nearly 60 years. As a young legislator, he presided over the House during the vote to approve Medicare in 1965.

As a tribute to his father, who served before him and who introduced the first congressional legislation to establish national health insurance during the New Deal, Dingell introduced his own national health insurance bill at the start of every Congress.

And when the House passed what would become the Affordable Care Act in 2009, leaders named the legislation after him. Dingell sat by the side of President Barack Obama when he signed the bill into law in 2010.

Dingell was “a beloved pillar of the Congress and one of the greatest legislators in American history,” said a statement from House Speaker Nancy Pelosi. “Yet, among the vast array of historic legislative achievements, few hold greater meaning than his tireless commitment to the health of the American people.”

He was not always nice. Dingell had a quick temper and a ferocious demeanor when he was displeased, which was often. Witnesses who testified before him could feel his wrath, as could Republican opponents and even other committee Democrats. And he was fiercely protective of his committee’s territory.

In 1993, during the effort by President Bill Clinton to pass major health reform, as the heads of the three main committees that oversee health issues argued over which would lead the effort, Dingell famously proclaimed of his panel, “We have health.”

Dingell and his health subcommittee chairman, California Democrat Henry Waxman, fought endlessly over energy and environmental issues. Waxman, who represented an area that included western Los Angeles, was one of the House’s most active environmentalists. Dingell represented the powerful auto industry in southeastern Michigan and opposed many efforts to require safety equipment and fuel and emission standards.

In 2008, Waxman ousted Dingell from the chairmanship of the full committee.

But the two were of the same mind on most health issues, and together during the 1980s and early 1990s they expanded the Medicaid program, reshaped Medicare and modernized the FDA, NIH and the Centers for Disease Control and Prevention.

“It was always a relief for me to know that when he and I met with the Senate in the conference, we were talking from the same page, believed in the same things, and we were going to fight together,” Waxman said in 2009.

Dingell was succeeded in his seat by his wife, Rep. Debbie Dingell, herself a former auto industry lobbyist.

House Panel Mulls ACA Fixes, Responses to Trump Policies

Now to the article of the week, Ryan Basen, a writer for MedPage noted that focusing on preventive care, expanding subsidies, and regulating association health plans (AHPs) were among the solutions proposed Tuesday to aid Americans with pre-existing health conditions, as the U.S. House Ways and Means Committee held its first hearing under the new Congress.

While the hearing was entitled “Protecting Americans with Pre-Existing Conditions,” much discussion centered around the policies within the Affordable Care Act, Republican efforts to repeal it, and recent reforms that tweaked American healthcare. Many lawmakers used their allotted time to blast other party members for either being too supportive of the ACA or attempting to “sabotage” it. Some lawmakers, however, promised to work together with members of the opposing party to help patients with pre-existing conditions — which some noted includes themselves and family members.

“Protections for people with pre-existing conditions has become the defining feature of the Affordable Care Act,” said witness Karen Pollitz, a senior fellow with the Kaiser Family Foundation; she noted that these protections also enjoy widespread public support.

The ACA forced insurance plans to accept and retain members with pre-existing conditions, many of whom could not afford plans before the legislation was enacted. But Trump administration policies and other reforms worry some experts and lawmakers that the millions of American with pre-existing conditions — ranging from moderate mental health diagnoses to cancer — are gradually being priced out of the healthcare system again, they said.

Protecting patients with pre-existing conditions are linked to controlling costs throughout American healthcare, many said. Recent legislation led to “artificial” cost increases for ACA marketplace plans and pushed some insurers to leave the market altogether, Pollitz said. These policies also have driven up premium prices.

“What we have here is an infrastructure problem,” Rep. John Larson (D-Conn.) said. “The disagreements are over how to pay for it.”

“All we are really debating here is who gets to pay,” Rep. David Schweikert (R-Ariz.) said. “It’s time for radical rethinking: Are you [Democrats] willing to work with us to break down the barriers to having cost disruption?”

Several who spoke Tuesday offered potential solutions. Witness Keysha Brooks-Coley, of the American Cancer Society Cancer Action Network, suggested lawmakers strengthen the ACA by addressing its so-called “family glitch” and eliminating the “subsidy cliff”; both policies currently withhold subsidies from many Americans who need them to pay for healthcare, she said.

Rep. Brad Wenstrup, DPM (R-Ohio), called for turning lawmakers’ focus from squabbling about politics to studying preventative care. “There’s no part of me as a doctor that doesn’t want Americans to have access to quality healthcare,” the podiatrist said. “But I don’t necessarily agree with the direction (the ACA) went.”

“Let’s talk about incentivizing health: What do we have not only for the patient but for the physician?” he added. “Think about who gets rewarded in today’s system. Do we recognize the doctor who prevented the patient from needing open-heart surgery? That’s where we need to go if you want to talk about the cost curve.”

One solution is actually quite simple, according to witness Rob Roberston, secretary-treasurer for the Nebraska Farm Bureau: regulate AHPs and encourage individuals to band together in groups to reduce premium costs, as many farmers and ranchers have in Nebraska. “This is not a political issue,” he said. “This is an issue of hardship, and we need to fix these individual markets and protect pre-existing conditions at the same time.”

Alas, judging by many lawmakers’ tone during a hearing that stretched over four hours, this does appear to be a political issue. “It’s really this long debate over Obamacare,” Rep. Devin Nunes (R-Calif.) said. “We really need to work for a solution because Obamacare wasn’t a solution.”

Rep. Lloyd Doggett (D-Texas) then got into it. “What has led us here has been eight years of Republican persistence in trying to destroy the Affordable Care Act,” he said. “It’s great to hear they [Republicans] want to work with us and I hope they do.” The ACA is not perfect, Doggett acknowledged, but he quipped that perhaps “the most pre-existing condition” present Tuesday was “the political amnesia of those who have forgotten what it was like before the Affordable Care Act.”

Raising his voice, Rep. Earl Blumenauer (D-Ore.) echoed the point: “If we would have been working together for the last six years to refine the Affordable Care Act, costs would be lower, coverage would be better.”

Many witnesses spoke against the Administration’s policy to loosen regulations on cheaper short-term plans that do not have to abide by ACA strictures. “The expansion of these plans does not help the consumer,” Brooks-Coley said. “It puts them at increased risk. … They are only less expensive upfront because they don’t cover [serious conditions].” In addition, Pollitz noted, many of these plans drop patients once they become ill and “have been shown to increase costs of ACA-compliant plans.”

The witnesses were asked to gauge what would happen if protections for patients with pre-existing conditions were to be removed. Younger women would pay more than men the same age, Pollitz said, and all pre-existing patients “would find it much more difficult to find coverage.”

“True harm would come,” Andrew Stolfi, Oregon Division of Financial Regulation’s insurance commissioner, told the committee. He cited Oregon’s pre-ACA experience: “You were lucky if you were even given the choice to take an insurer’s limited terms.”

Ways and Means chairman Richard Neal (D-Mass.) ended the hearing with optimism: “Today I heard a lot of members on the other side of the aisle say they support [requiring coverage for] pre-existing conditions, and I welcome that and hope we can work together.”

So, now what do the physicians think is needed to improve our health care system? Next week let’s discuss.

The children in Washington are still fighting over the wall but, my wife found out why I’m not a fan of Medicare-For-All this past weekend. She finally found out how expensive it is for our family, which is just the two of us. She added up the fees, including secondary insurance, etc. and it came up with a yearly cost of $13,000. So, there is nothing free here. And if the government pays these costs to imagine the cost and who is going to pay for this program?

Jack Crowe from the National Review reported that Senator Kamala Harris (D., Calif.) advocated the elimination of the private health insurance industry during a CNN town hall event in Iowa Monday night.

Harris, who announced her 2020 presidential candidacy this week, broke from previous Democratic healthcare orthodoxy, which held that Americans could retain their private insurance if they so chose, in favor of a single-payer plan in which the government is the sole health insurance provider.

“I believe the solution — and I actually feel very strongly about this — is that we need to have Medicare for all,” Harris said in response to an audience question about healthcare affordability. “That’s just the bottom line.”

“So for people out there who like their insurance, they don’t get to keep it?” CNN’s Jake Tapper asked.

“Let’s eliminate all of that,” Harris responded, “let’s move on.”

Harris went on to describe the current healthcare system as “inhumane” and argued that switching over to a single payer system would reduce the financial and bureaucratic barriers to quality health care.

“Well, listen, the idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require,” she said. “Who of us has not had that situation where you’ve got to wait for approval, and the doctor says, well, I don’t know if your insurance company is going to cover this. Let’s eliminate all of that. Let’s move on.”

Employing the language of human rights, the Democratic establishment has increasingly embraced “Medicare For All” in recent years as young, healthy Americans — previously burdened by the threat of a punitive tax on the uninsured, which the Trump administration recently eliminated — have increasingly fled government exchanges, exposing older, sick consumers to even steeper premiums.

The policy, which is widely viewed as a litmus test among potential Democratic presidential candidates, mandates that every American purchase their health insurance through the government. It would require $32.6 trillion in new spending over ten years, according to the Mercatus Center. Doubling the corporate and individual income tax would not cover the cost of the program, according to the analysis.

Jack Crowe then followed up on this announcement by Harris noting that after advocating the elimination of the private insurance market during CNN’s town hall in Iowa Monday night, Senator Kamala Harris (D., Calif.) appeared to backtrack on Tuesday amid criticism from moderate Democrats and Republicans alike.

Remember her announcement “Let’s eliminate all of that,” Harris said when asked by CNN’s Jake Tapper if, under her proposed “Medicare For All” proposal, Americans with private insurance plans could retain them.

“Let’s move on,” she added.

The remarks immediately drew condemnation from former Starbucks CEO Howard Schultz, who recently launched an independent bid for president, and Mike Bloomberg, the centrist former mayor of New York City.

In response, Harris’s national press secretary Ian Sams and an unnamed advisor told CNN that she would also be open to pursuing more moderate healthcare reforms that would allow the 177 million Americans currently using private health insurance plans to keep them.

“Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period,” Sams told CNN. “She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.”

During her time in the Senate, Harris has co-sponsored Senator Bernie Sanders (D., Vt.) “Medicare For All” bill, which would entirely phase out the private insurance industry, but has also proven willing to embrace the more moderate “public option,” which would allow more Americans to buy into Medicaid while leaving the private market largely intact.

Kamala Harris and the Implausibility of ‘Medicare-for-All’

Then Rich Lowry noted that Senator Kamala Harris committed a most unusual gaffe at her CNN town hall the other night — not by misspeaking about one of her central policy proposals, but by describing it accurately.

Asked on Monday night if the “Medicare-for-all” plan that she’s co-sponsoring with Senator Bernie Sanders eliminates private health insurance, she said that it most certainly does. Citing insurance company paperwork and delays, she waved her hand: “Let’s eliminate all of that. Let’s move on.”

She met with approbation from the friendly audience in Des Moines, Iowa, but the reaction elsewhere was swift and negative.

“As the furor grew,” CNN reported the next day, “a Harris adviser on Tuesday signaled that the candidate would also be open to the more moderate health reform plans, which would preserve the industry, being floated by other congressional Democrats.”

This was a leading Democrat wobbling on one of her top priorities 48 hours after the kickoff of her presidential campaign, which has been praised for its early acumen. It is sure to be the first of many unpleasant encounters between the new Democratic agenda and political reality.

Democrats are now moving from the hothouse phase of jockeying for the nomination, when all they had to do was get on board the party’s orthodoxy as defined by Bernie Sanders, to defending these ideas in the context of possibly signing them into law as president of the United States.

The Harris flap shows that insufficient thought has been given to how these proposals will strike people not already favorably disposed to the new socialism. It’s one thing for Sanders to favor eliminating private health insurance; no one has ever believed that he is likely to become president. It’s another for Harris, deemed a possible front-runner, to say it.

Her position is jaw-droppingly radical. It flips the script of the (dishonest) Barack Obama pledge so essential to passing Obamacare: “If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.”

That was a very 2009 sentiment. Ten years later, Harris indeed wants to take away your health plan, not in a stealthy operation, not as an unfortunate byproduct of the rest of her plan, but as a defining plank of her agenda.

This is a far more disruptive idea than Senator Elizabeth Warren’s wealth tax. The affected population isn’t a limited group of highly affluent people. It is half the population, roughly 180 million people who aren’t eager for the government to swoop in and nullify their current health-care arrangements.

They may not like the current system, but they like their own health care — about three-quarters tell Gallup that their own health care is excellent or good. This is why the relatively minor interruption of private plans as part of the rollout of Obamacare was so radioactive.

How is a President Harris going to overcome this kind of resistance absent Depression-era Democratic supermajorities in Congress? Not to mention pay for a program that might well cost $30 trillion over 10 years and beat back fierce opposition from key players in the health-care industry?

She obviously won’t. “Medicare-for-all” is a wish and a talking point rather than a realistic policy. When her aides say she is willing to accept another “path” to “Medicare-for-all,” what they mean is that Harris is willing to accept something short of true “Medicare-for-all.”

There is always something to be said for shifting the Overton window on policy. But it’s better if think tanks and gadflies rather than plausible presidential candidates who aren’t even trying to hold down the left flank of the party do that.

If it’s uncomfortable for Kamala Harris to defend eliminating private health insurance now, imagine what it will be like when the entire apparatus of the Republican Party — including the president’s Twitter feed — is aimed at her in a general election.

What do Californians think about Kamala Harris’ far-left agenda?

Campus Reform editor-in-chief Lawrence Jones hit the streets of Los Angeles to see how people view the 2020 Democratic presidential candidate’s progressive proposals.

People expressed enthusiasm for Harris’ agenda, which includes Medicare-for-all, free college and rolling back President Trump’s tax plan.

When asked how they would pay for healthcare and college for every American, people responded with “Figure it out!” and “It’s in someone’s pockets, so why not share?”

On “Fox & Friends” Thursday, Jones said he spoke to many people who acknowledged that Harris’ agenda is not affordable or practical, but they like her and what she’s saying.

“This just shows you where this emotion-driven, progressive policy has taken this country,” Jones said.

He said Campus Reform has explored that troubling trend on college campuses, and now he’s increasingly seeing it among adults.

“That’s why people should be concerned because Obama won because he connected with voters,” Jones said. “Let’s see what happens now.”

‘Medicare-for-all’ means long waits for poor care, and Americans won’t go for it once they learn these facts

Progressive Democrats push ‘Medicare-for-all’ platform.

Critics say to provide ‘Medicare-for-all,’ taxes would have to go up while quality, choice, and access to care would go down; chief congressional correspondent Mike Emanuel reports.

Sally Pipes of Fox News pointed out that this week, as I have already stated, Sen. Kamala Harris, D-Calif., one of the front-runners in the race for the Democratic Party’s presidential nomination, revealed her radical vision for American health care – outlawing private health insurance and putting the government in charge of the system.

Harris, along with 15 of her Democratic colleagues, supports Sen. Bernie Sanders’, I-Vt., the vision of “Medicare-for-all.” Sanders’ 2017 bill, S.1804, was explicit about outlawing private health insurance. At a town hall in Iowa last Again, remember Monday when Harris confirmed she was on board with that idea. “Let’s eliminate all of that,” she said.

In other words, Harris is running for president on a platform of taking away the private insurance coverage of about 200 million people and dumping everyone into a one-size-fits-all government-run health plan that would cost taxpayers trillions of dollars. And if the experiences of other countries with single-payer health care are any indication, it would result in long waits for poor care.

I’M A NOT A DEMOCRAT, ACTUALLY AN INDEPENDENT, BUT MEDICARE FOR ALL IS NOT THE ANSWER — HERE ARE FOUR SUGGESTIONS

Support for single-payer appears to be the price of admission to the Democratic presidential race. Harris’s fellow presidential aspirants, Sens. Elizabeth Warren, D-Mass., Kirsten Gillibrand, D-N.Y., and Cory Booker, D.-N.J., were among the co-sponsors of Sanders’ 2017 “Medicare-for-all” legislation. And it’s only a matter of time before Sanders himself, the pied piper of the “Medicare-for-all” movement, joins the race.

“Medicare-for-all’s” advocates promise a health care system that’s free at the point of service – no co-pays, no deductibles, no coinsurance.

They tend to be less upfront about how they’d pay for it. Independent estimates from both the right and the left peg “Medicare-for-all’s” cost at about $32 trillion over 10 years. Doubling what the federal government takes in individual and corporate income tax revenue wouldn’t be enough to cover that tab.

That’s assuming “Medicare-for-all” is able to implement its financing strategy. The bill proposes reimbursing doctors and hospitals at Medicare’s current rates, which are 40 percent below what private insurance pays.

Health care providers are unlikely to just absorb those cuts. Those with narrow margins – say, in rural areas – may be forced to close, unable to cover their costs. Some doctors may respond to lower payments by seeing fewer patients, retiring early, or leaving the practice of medicine altogether. Bright young people may decide not to pursue careers in medicine, given that “Medicare for all” will limit their earning power.

Regardless, ratcheting down the price of care by force is going to cause health care providers to supply less of it. And that will lead to longer waits for patients.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring.

Long waits plague patients in other countries with government-run health care. Take Canada, which outlaws private health insurance for anything considered medically necessary, just as “Medicare for all” would. The median wait for treatment from a specialist following referral by a general practitioner is 19.8 weeks, according to the Fraser Institute, a Vancouver-based think tank. In 1993, the median wait was less than half as much – 9.3 weeks.

Waits are far longer for some specialties. For orthopedic surgery, the median wait for specialist treatment is 39 weeks.

Many Canadians are uninterested in waiting multiple months for treatment, particularly if they’re in pain or fear they may have a serious illness. So they pay out of pocket for care abroad. In 2016, more than 63,000 Canadians went to another country to receive medical treatment.

On the other side of the Atlantic, the United Kingdom’s government-run, 70-year old National Health Service, is proving similarly incapable of providing quality care. The system is currently short 100,000 health professionals – doctors, nurses, and other workers.

It’s no wonder 14 percent of operations are canceled right before they are supposed to happen, usually due to a shortage of staff or beds. Last July, 4.3 million patients were waiting for an operation – the highest figure in a decade.

During the winter, the system goes into crisis mode. Between December 2017 and February 2018, more than 163,000 patients waited in corridors and ambulances for over 30 minutes before being admitted to the emergency room. To deal with the crunch, officials ordered hospitals to cancel 50,000 operations.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring. A majority of people, 55 percent, erroneously believes that they’d be able to keep their private insurance under such a system. Once they learn it would eliminate private health insurance, support for the idea plummets, from 56 percent to 37 percent. The same happens after they learn it would require higher taxes.

Seven in 10 Americans say they’d oppose “Medicare-for-all” if it led to delays in getting some treatments and tests. Such delays are not hypothetical – they’re endemic to single-payer.

Harris and her fellow Democrats may think “Medicare-for-all” is their ticket to the White House. But voters are not interested in their plan to eliminate private health insurance.

And now, this past week, one of the potential Presidential candidates Senator Kirsten Gillibrand a backer of Medicare-For-All, announced that she thought that Medicaid-For-All made sense also. Really, do you all know what Medicaid pays the physicians???? 10 cents on the dollar, which is why my practice doesn’t accept any Medicaid patients. But maybe for primary care using nurse practitioners and physician assistants, this might work as basic care for “All”.

So, one of the options that the Democrats are pushing is “Medicare-for-All.” But do the voters like the idea? Ricardo Alonso-Zaldivar noted that Americans like the idea of “Medicare-for-all,” but support flips to disapproval if it would result in higher taxes or longer waits for care. Then how will the plan be financed?

That’s a key insight from a national poll released Wednesday by the nonpartisan Kaiser Family Foundation. It comes as Democratic presidential hopefuls embrace the idea of a government-run health care system, considered outside the mainstream of their party until Vermont independent Sen. Bernie Sanders made it the cornerstone of his 2016 campaign. President Donald Trump is opposed, saying “Medicare-for-all” would “eviscerate” the current program for seniors.

The poll found that Americans initially support “Medicare-for-all,” 56 percent to 42 percent.

However, those numbers shifted dramatically when people were asked about the potential impact, pro, and con.

Support increased when people were told “Medicare-for-all” would guarantee health insurance as a right (71 percent) and eliminates premiums and reduce out-of-pocket costs (67 percent).

But if they were told that a government-run system could lead to delays in getting care or higher taxes, support plunged to 26 percent and 37 percent, respectively. Support fell to 32 percent if it would threaten the current Medicare program.

“The issue that will really be fundamental would be the tax issue,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who reviewed the poll. He pointed out those state single-payer efforts in Vermont and Colorado failed because of concerns about the tax increases needed to put them in place.

There doesn’t seem to be much disagreement that a single-payer system would require tax increases since the government would take over premiums now paid by employers and individuals as it replaces the private health insurance industry. The question is how much.

Several independent studies have estimated that government spending on health care would increase dramatically, in the range of about $25 trillion to $35 trillion or more over a 10-year period. But a recent estimate from the Political Economy Research Institute at the University of Massachusetts in Amherst suggests that it could be much lower. With significant cost savings, the government would need to raise about $1.1 trillion from new revenue sources in the first year of the new program.

House Budget Committee Chairman John Yarmuth, D-Ky., has asked the Congressional Budget Office for a comprehensive report on single-payer. The CBO is a nonpartisan outfit that analyzes the potential cost and impact of legislation. Its estimate that millions would be made uninsured by Republican bills to repeal the Affordable Care Act was key to the survival of President Barack Obama’s health care law.

Mollyann Brodie, director of the Kaiser poll, said the big swings in approval and disapproval show that the debate over “Medicare-for-all” is in its infancy. “You immediately see that opinion is not set in stone on this issue,” she said.

Indeed, the poll found that many people are still unaware of some of the basic implications of a national health plan.

For example, most working-age people currently covered by an employer (55 percent) said they would be able to keep their current plan under a government-run system, while 37 percent correctly answered that they would not.

There’s one exception: Under a “Medicare-for-all” idea from the Center for American Progress employers and individuals would have the choice of joining the government plan, although it wouldn’t be required. Sanders’ bill would forbid employers from offering coverage that duplicates benefits under the new government plan.

“Medicare-for-all” is a key issue energizing the Democratic base ahead of the 2020 presidential election, but Republicans are solidly opposed.

“Any public debate about ‘Medicare-for-all’ will be a divisive issue for the country at large,” Brodie said.

The poll indicated widespread support for two other ideas advanced by Democrats as alternatives to a health care system fully run by the government.

Majorities across the political spectrum backed allowing people ages 50-64 to buy into Medicare, as well as allowing people who don’t have health insurance on the job to buy into their state’s Medicaid program.

Separately, another private survey out Wednesday finds the uninsured rate among U.S. adults rose to 13.7 percent in the last three months of 2018. The Gallup National Health and Well-Being Index found an increase of 2.8 percentage points since 2016, the year Trump was elected promising to repeal “Obamacare.” That would translate to about 7 million more uninsured adults.

Government surveys have found that the uninsured rate has remained essentially stable under Trump.

The Kaiser Health Tracking Poll was conducted Jan. 9-14 and involved random calls to the cellphones and landlines of 1,190 adults. The margin of sampling error for all respondents is plus or minus 3 percentage points.

Trump Seeks Action To Stop Surprise Medical Bills

A healthcare reporter, Emmarie Huettman reported that President Trump instructed administration officials Wednesday to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in health care.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump directed his health secretary, Alex Azar, and labor secretary, Alex Acosta, to work on a solution, several attendees said.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with “the biggest teeth you can find.”

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or isn’t covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News, NPR, Vox and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said the 10 invited guests — patients as well as doctors — were given an opportunity to tell their story, though Trump didn’t stay to hear all of them during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose daughter’s experience with a $17,850 bill for a urine test after back surgery was detailed in February 2018 in KHN-NPR’s first Bill of the Month feature.

Davis’ daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it.

Such tests rarely cost more than $200, a fraction of what the lab charged Moreno and her insurance company. But fearing damage to his daughter’s credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general’s office, alleging “price gouging of staggering proportions.”

Davis said White House officials made it clear that price transparency is a “high priority” for Trump, and while they didn’t see eye to eye on every subject, he said he was struck by the administration’s sincerity.

“These people seemed earnest in wanting to do something constructive to fix this,” Davis said.

Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins University who has written about transparency in health care and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

“This is how most of America lives, and [Americans are] getting hammered,” he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation’s health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar, and Acosta said efforts to control costs in health care were yielding positive results, discussing, in particular, the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans “want to see what we’re doing, like today we lowered prescription drug prices, the first time in 50 years,” according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said “growth in relative drug prices has slowed since January 2017,” not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs, patents have expired on brand-name drugs and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C.

Drugmakers were also wary of increasing their prices in the midst of growing political pressure, though the pace of increases has risen recently.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with health care, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a “sweeping” investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

The Ground Game for Medicaid Expansion: ‘Socialism’ or a Benefit for All?

One of the other options is that of expanding Medicaid but is that socialism or a benefit for all. Michael Ollove noted that a yard sign in Omaha promotes Initiative 427, which would expand Medicaid in Nebraska. Voters in the red states of Idaho and Utah also will decide whether to join 33 states and Washington, D.C., in extending Medicaid benefits to more low-income Americans as envisioned by the Affordable Care Act. Montana voters will decide whether to make expansion permanent.

Nati Harnik noted that on a sun-drenched, late October afternoon, Kate Wolfe and April Block are canvassing for votes in a well-tended block of homes where ghosts and zombies compete for lawn space with Cornhusker regalia. Block leads the way with her clipboard, and Wolfe trails behind, toting signs promoting Initiative 427, a ballot measure that, if passed, would expand Medicaid in this bright red state.

Approaching the next tidy house on their list, they spot a middle-aged woman with a bobbed haircut pacing in front of the garage with a cellphone to her ear.

Wolfe and Block pause, wondering if they should wait for the woman to finish her call when she hails them. “Yes, I’m for Medicaid expansion,” she calls. “Put a sign up on my lawn if you want to.” Then she resumes her phone conversation.

Apart from one or two turndowns, this is the sort of warm welcome the canvassers experience this afternoon. Maybe that’s not so surprising even though this is a state President Donald Trump, an ardent opponent of “Obamacare,” or the Affordable Care Act, carried by 25 points two years ago.

Although there has been no public polling, even the speaker of the state’s unicameral legislature, Jim Scheer, one of 11 Republican state senators who signed an editorial last month opposing the initiative, said he is all but resigned to passage. “I believe it will pass fairly handily,” he told Stateline late last month.

Anne Garwood (left), a tech writer, and April Block, a middle school teacher, review voter lists in preparation for canvassing an Omaha neighborhood in favor of Initiative 427, which would expand Medicaid in Nebraska.

The Pew Charitable Trusts

Bills to expand eligibility for Medicaid, the health plan for the poor run jointly by the federal and state governments, have been introduced in the Nebraska legislature for six straight years. All failed. Senate opponents said the state couldn’t afford it. The federal government couldn’t be counted on to continue to fund its portion. Too many people were looking for a government handout.

Now, voters will decide for themselves.

Nebraska isn’t the only red state where residents have forced expansion onto Tuesday’s ballot. Idaho and Utah voters also will vote on citizen-initiated measures on Medicaid expansion. Montana, meanwhile, will decide whether to make its expansion permanent. The majority-Republican legislature expanded Medicaid in 2015, but only for a four-year period that ends next July.

Polling in those three states indicates a majority supports expanding Medicaid. Like Nebraska, all are heavily Republican states easily captured by Trump in 2016.

Last year’s failed attempt by Trump and congressional Republicans to unravel Obamacare revealed the popularity of the ACA with voters. Health policy experts said it also helped educate the public about the benefits of Medicaid, prompting activists in the four states to circumvent their Republican-led legislatures and take the matter directly to the voters.

Activists also were encouraged by the example of Maine, where nearly 60 percent of voters last year approved Medicaid expansion after the state’s Republican governor vetoed expansion bills five times.

“Medicaid has always polled well,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “When you explain what it does, they think it’s a good idea. What has changed is the intensity and growing recognition that states without expansion are falling further behind, especially in rural areas where hospitals are closing at an alarming rate.

“And all of the states with these ballot initiatives this year have significant rural populations.”

For many in Nebraska, the argument — advanced in one anti-427 television ad — that Medicaid is a government handout to lazy, poor people simply doesn’t square with what they know.

“These aren’t lazy, no-good people who refuse to work,” said Block, a middle school teacher, in an exasperating tone you can imagine her using in an unruly classroom. “They’re grocery store baggers, home health workers, hairdressers. They are the hardest workers in the world, who shouldn’t have to choose between paying for rent or food and paying for medicine or to see a doctor.”

Extending Benefits to Childless Adults

The initiative campaign began after the Nebraska legislature refused to take up expansion again last year. Its early organizers were, among others, a couple of Democratic senators and a nonprofit called Nebraska Appleseed.

Calling itself “Insure the Good Life,” an expansion of the state slogan, the campaign needed nearly 85,000 signatures to get onto the ballot. In July, the group submitted 136,000 signatures gathered from all 93 Nebraska counties.

The initiative would expand Medicaid to childless adults whose income is 138 percent of the federal poverty line or less. For an individual in Nebraska, that would translate to an income of $16,753 or less. Right now, Nebraska is one of 17 states that don’t extend Medicaid benefits to childless adults, no matter how low their income.

Under Medicaid expansion, the federal government would pay 90 percent of the health care costs of newly eligible enrollees, and the state would be responsible for the rest. The federal match for those currently covered by Medicaid is just above 52 percent.

The Nebraska Legislative Fiscal Office, a nonprofit branch of the legislature, found in an analysis that expansion would bring an additional 87,000 Nebraskans into Medicaid at an added cost to the state of close to $40 million a year. The current Medicaid population in Nebraska is about 245,000.

The federal government would send an additional $570 million a year to cover the new enrollees. An analysis from the University of Nebraska commissioned by the Nebraska Hospital Association, a backer of the initiative, found the new monies also would produce 10,800 new jobs and help bolster the precarious financial situation of the state’s rural hospitals.

For economic reasons alone, not expanding makes little sense, said state Sen. John McCollister, one of two Republican senators openly supporting expansion and a sponsor of expansion bills in the legislature, over coffee in an Omaha cafe one day recently.

“Nebraska is sending money to Washington, and that money is being sent back to 33 other states and not to Nebraska,” he said. “It’s obviously good for 90,000 Nebraskans by giving them longevity and a higher quality of life, but it also leads to a better workforce and benefits rural hospitals that won’t have to spend so much on uncompensated care.”

He said the state could easily raise the necessary money by increasing taxes on medical providers, cigarettes and internet sales. If 427 passes, those will be decisions for the next legislature.

Among the measure’s opponents are Americans for Prosperity, a libertarian advocacy group funded by David and Charles Koch that has been running radio ads against the initiative. Jessica Shelburn, the group’s state director in Nebraska, said her primary concern is that expansion would divert precious state resources and prompt cutbacks in the current optional services Medicaid provides.

“While proponents have their hearts in the right place,” Shelburn said, “we could end up hurting the people Medicaid is intended to help.”

Georgetown’s Alker, however, said that no expansion state has curtailed Medicaid services.

When the Affordable Care Act passed in 2010, it mandated that all states expand Medicaid, but a 2012 U.S. Supreme Court ruling made expansion optional for the states. As of now, 33 states and Washington, D.C., have expanded, including states that tend to vote Republican, such as Alaska, Arkansas, and Indiana.

Expansion is not an election issue only in the states with ballot initiatives this year. Democratic gubernatorial candidates are making expansion a major part of their campaigns in Florida and Georgia.

Ashley Anderson, a 25-year-old from Omaha with epilepsy, is one of those anxiously hoping for passage in Nebraska. A rosy-faced woman, she wears a red polo shirt from OfficeMax, where she works part-time for $9.50 an hour in the print center. She aged out of Medicaid at 19, and her single mother can’t afford a family health plan through her employer.

Since then, because of Anderson’s semi-regular seizures, she says she can’t take a full-time job that provides health benefits, and private insurance is beyond her means.

Because Anderson also can’t afford to see a neurologist, she is still taking the medication she was prescribed as a child, even though it causes severe side effects.

Not long ago, Anderson had a grand mal seizure, which entailed convulsions and violent vomiting, and was taken by ambulance to the emergency room. That trip left her $2,000 in debt. For that reason, she said, “At this point, I won’t even call 911.”

Anderson might well qualify for Social Security disability benefits, which would entitle her to Medicaid, but she said the application process is laborious and requires documentation she does not have. As far as she is concerned, the initiative is her only hope for a change.

“You know what, I even miss having an MRI,” she said. “I’m supposed to have one every year.” She can’t remember the last time she had one.

For the uninsured, the alternatives are emergency rooms or federally qualified health centers, which do not turn away anyone because of poverty.

While the clinics provide primary care, dental care, and mental health treatment, they cannot provide specialty care or perform diagnostic tests such as MRIs or CAT scans, said Ken McMorris, CEO of Charles Drew Health Center, the oldest community health center in Nebraska, which served just under 12,000 patients last year.

Almost all its patients have incomes below 200 percent of poverty, McMorris said. Many have little access to healthy foods and little opportunity for exercise.

William Ostdiek, the clinic’s chief medical officer, said he constantly sees patients with chronic conditions such as diabetes and cardiovascular disease whose symptoms are getting worse because they cannot afford to see specialists.

“It’s becoming a vicious cycle,” he said. “They face financial barriers to the treatments they need, which would enable them to have full, productive lives. Instead, they just get sicker and sicker.”

Expansion, McMorris said, would make all the difference for many of those patients.

Some county officials also hope for passage. Mary Ann Borgeson, a Republican county commissioner in Douglas County, which includes Omaha, said her board has always urged the legislature to pass expansion. “Most people don’t understand — for counties, the Medicaid is a lifeline for many people who otherwise lack health care.”

Consequently, she said, the county pays about $2 million a year to reimburse providers for giving care to people who don’t qualify for Medicaid and can’t afford treatment, money that would otherwise be in the pockets of county residents.

‘That Is Socialism’

Insure the Good Life has raised $2.2 million in support of 427, according to campaign finance reports and Meg Mandy, who directs the campaign. Significant contributions have come from outside the state, particularly from Families USA, a Washington-based advocacy organization promoting health care for all, and the Fairness Project, a California organization that supports economic justice.

Both groups are active in the other states with expansion on the ballot. Well-financed, the proponents have a visible ground game and a robust television campaign.

The opposition, much less evident, is led by an anti-tax Nebraska organization called the Alliance for Taxpayers, which has filed no campaign finance documents with the state.

Marc Kaschke, former mayor of North Platte, said he is the organization’s president, but referred all questions about finances to an attorney, Gail Gitcho, who did not respond to messages left at her office.

Gitcho had previously told the Omaha World-Herald that the group hadn’t been required to file finance reports because its ads only provided information about 427; it doesn’t directly ask voters to cast ballots against the initiative.

Last week, the Alliance for Taxpayers began airing its first campaign ads. One of them complains that the expansion would give “free health care” to able-bodied adults. It features a young, healthy-looking, bearded man, slouched on a couch and eating potato chips, with crumbs spilled over his chest.

In a phone interview, Kaschke made familiar arguments against expansion. He said the state can’t afford the expansion, that it would drain money from other priorities, such as schools and roads. He said he fears the federal government would one day stop paying its share, leaving the states to pay for the whole program.

He also said, repeating Shelburn’s claim, that with limited funds, the state would be forced to cut back services to the existing population.

“We feel the states would be in a better position to solve this problem of health care,” Kaschke said. He didn’t offer suggestions on how.

Outside influence ruffles many Nebraska voters. Duane Lienemann, a retired public school agricultural teacher from Webster County near the Kansas line, said he resents outside groups coming to the state telling Nebraskans how to vote.

And he resents “liberals” from Omaha trying to shove their beliefs down the throats of those living in rural areas.

Their beliefs about expansion don’t fly with him.

“I think history will tell you when you take money away from taxpayers and give it to people as an entitlement, it is not sustainable,” Lienemann said. “You cannot grow an economy through transferring money by the government. That is socialism.”

It’s a view shared by Nebraska’s Republican governor, Pete Ricketts. He is on record opposing the expansion, repeating claims that it would force cutbacks in other government services and disputing claims, documented in expansion states, that expansion leads to job growth. But Ricketts has not made opposition to expansion a central part of his campaign.

Whether he would follow in the path of Maine’s Republican governor, Paul LePage, and seek to block implementation of the expansion if the initiative passed, is not clear. Ricketts’ office declined an interview request and did not clarify his position on blocking implementation.

For his part, Scheer, the speaker of the legislature, said he would have no part of that. “We’re elected to fulfill the wishes of the people,” he said. “If it passes, the people spoke.”

Rural Hospitals in Greater Jeopardy in the Non-Medicaid Expansion States

Michael Ollove reported that after marching 130 miles from rural Belhaven, North Carolina, to the state Capitol in Raleigh, protesters in 2015 rally against the closing of their hospital, Vidant Pungo. Medicaid expansion could be the difference between survival and extinction for many rural hospitals.

In crime novelist Agatha Christie’s biggest hit, “And Then There Were None,” guests at an island mansion die suspicious deaths one after another.

So you can forgive Jeff Lyle, a big fan of Christie’s, for comparing the 36-bed community hospital he runs in Marlin, Texas, to one of those unfortunate guests. In December, two nearby hospitals, one almost 40 miles away, the other 60 miles away, closed their doors for good.

The closings were the latest in a trend that has seen 21 rural hospitals across Texas shuttered in the past six years, leaving 160 still operating.

Lyle, who is CEO, can’t help wondering whether his Falls Community Hospital will be next.

“Most assuredly,” he replied when asked whether he could envision his central Texas hospital going under. “We’re not using our reserves yet, but I can see them from here.”

It’s not just Texas: Nearly a hundred rural hospitals in the United States have closed since 2010, according to the Center for Health Services Research at UNC-Chapel Hill. Another 600-plus rural hospitals are at risk of closing, according to an oft-cited 2016 report by iVantage Health Analytics.

Texas had the most hospitals in danger of closing (75), the health metrics firm said. And Mississippi had the largest share of hospitals at risk (79 percent).

Neither state has expanded Medicaid eligibility to more of its low-income residents under the Affordable Care Act, also known as Obamacare. In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.

Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.

That is why Lyle and administrators of other rural hospitals in Texas and other non-expansion states are so adamant about their states joining the ranks of those that have expanded.

“It would mean a fair number of people we see who have no insurance would have insurance,” Lyle said. “And for us, a dollar is better than no dollar.”

In Texas, the expansion would make 1.2 million more people eligible for Medicaid, according to a 2018 Kaiser Family Foundation analysis. An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years.

Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.

By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.

The office of Republican Texas Gov. Greg Abbott and the most recent Republican chairmen of the health committees in the Texas legislature (the legislature has yet to make committee assignments for the current legislative session), Sen. Charles Schwertner and Rep. Four Price, did not return calls requesting comment for this story.

But not everyone believes Medicaid expansion is the answer to the problems facing rural hospitals. “Medicaid is as likely to prop up inefficient and wasteful hospitals as anything else,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Another rural hospital in Texas, Goodall-Witcher in Clifton, which also operates two community health clinics and a nursing room, risked closing until residents of Bosque County voted in November to create a hospital taxing district.

“I’m not saying we would have closed the day after the election,” said Adam Willmann, the hospital’s CEO, “but I don’t know how much longer we could have gone.”

The additional taxes will bring the hospital an estimated $2.5 million a year and perhaps take it out of the red, but they won’t necessarily lift Goodall-Witcher out of financial peril, Willmann said.

“Medicaid expansion,” Willmann said. “That is one of the key things we could do to help us deal with the tough financial demands we face.”

The burden of Uncompensated Care

As envisioned by the ACA when it passed Congress in 2010, expansion states would extend benefits to all adults — including childless adults — whose income was at or below 138 percent of the federal poverty line. (In 2019, that would be an average individual income of $12,140, depending on the state.)

Initially, the federal government paid 100 percent of the health care costs of the expansion population. The federal share falls to 90 percent in 2020.

To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.

Instead, many of those low-income residents remain uninsured or underinsured in plans with high deductibles and copayments.

But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.

Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes, and operating margins are so low that “uncompensated care” burdens can be crippling.

For instance, Willmann said his hospital’s uncompensated tab last year was about $4.2 million, or 11 to 12 percent of his overall budget.

According to the Oklahoma Hospital Association, the state’s rural hospitals carried about $170 million in bad debt from charitable care and patients’ unpaid bills. Five rural hospitals have closed in the state since 2016.

A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014 when states began implementing the expansion. At the same time, closure rates decreased in expansion states.

Many administrators of rural hospitals are quick to say that Medicaid expansion alone will not solve their financial problems. Rural hospitals faced steep challenges long before the ACA.

Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.

“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.

Automatic federal budget cuts beginning in 2013 (known as sequestration) reduced Medicare reimbursements, which are a particularly important source of revenue for hospitals. Congress has cut back on the amount hospitals can deduct for bad debt. Congress, in its budget tightening, reduced other forms of assistance to rural hospitals as well.

“You can put a Band-Aid on, but you still have 99 other wounds,” Willmann said.

Elehwany, of the National Rural Health Association, said that rural communities where hospitals are forced to close might be able to meet residents’ health needs by opening a new urgent care facility or maternal care center.

The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.

Goodall-Witcher Hospital is the largest employer in Bosque County. “Our payroll is bigger than the county’s entire budget,” Willmann said. “Can you imagine what it would do to this county to lose $9 million from the economy a year?”

A Health Services Research journal report found that when a rural area’s only hospital closes, income per capita falls by 4 percent and unemployment rises by 1.6 percent.

Willmann was relieved voters in his district supported the measure to create a hospital taxing district, but he acknowledged that it wasn’t a good deal for his county’s taxpayers. Their federal taxes help pay for the expansion in other states but not in Texas.

“Basically, you’re asking them to pay twice,” he said.

Rural hospital officials appear not to have the slightest hope that the deep red Texas legislature and the governor will get behind expansion.

“There is no likelihood of Medicaid expansion in Texas in the near term,” said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals.

The government shutdown is over, but for how long? The New York Times finally got it correct when they wrote:

‘Our Country Is Being Run by Children’: Shutdown’s End Brings Relief and Frustration

As the idiots in Congress still fight over the wall and continue to act like spoiled children we, the intelligent voters should be looking at healthcare delivery reality. What can we expect from these liberals and their cultural revolution? Joyce Frieden, the News Editor of MedPage Today pointed out last year that a reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

The effects of the recently passed tax bill.“If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that Medicaid, 60 million by Medicare, currently covers 74 million people and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

The increasing obesity problem.”Thirty percent of the U.S. population is obese; 70% of the total population is either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”

The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue of quality but there is a profound issue on costs.”

The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.

The lackluster performance of new payment models.”Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, the cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect the accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

VA Seeks to Redirect Billions of Dollars into Private Care

Jennifer Steinhauer and Dave Phillipps reported that The Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans’ hospitals to private health care providers, setting the stage for the biggest transformation of the veterans’ medical system in a generation.

Under proposed guidelines, it would be easier for veterans to receive care in privately run hospitals and have the government pay for it. Veterans would also be allowed access to a system of proposed walk-in clinics, which would serve as a bridge between V.A. emergency rooms and private providers, and would require co-pays for treatment.

Veterans’ hospitals, which treat seven million patients annually, have struggled to see patients on time in recent years, hit by a double crush of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 sent Congress searching for fixes, and in the years since, Republicans have pushed to send veterans to the private sector, while Democrats have favored increasing the number of doctors in the V.A.

If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the network founded by the billionaire industrialists Charles G. and David H. Koch, which has long championed increasing the use of private sector health care for veterans.

For individual veterans, private care could mean shorter waits, more choices and fewer requirements for co-pays — and could prove popular. But some health care experts and veterans’ groups say the change, which has no separate source of funding, would redirect money that the current veterans’ health care system — the largest in the nation — uses to provide specialty care.

Critics have also warned that switching vast numbers of veterans to private hospitals would strain care in the private sector and that costs for taxpayers could skyrocket. In addition, they say it could threaten the future of traditional veterans’ hospitals, some of which are already under review for consolidation or closing.

President Trump, who made reforming veterans’ health care a major point of his campaign, may reveal details of the plan in his State of the Union address later this month, according to several people in the administration and others outside it who have been briefed on the plan.

The proposed changes have grown out of health care legislation, known as the Mission Act, passed by the last Congress. Supporters, who have been influential in administration policy, argue that the new rules would streamline care available to veterans, whose health problems are many but whose numbers are shrinking, and also prod the veterans’ hospital system to compete for patients, making it more efficient.

“Most veterans chose to serve their country, so they should have the choice to access care in the community with their V.A. benefits — especially if the V.A. can’t serve them in a timely and convenient manner,” said Dan Caldwell, executive director of Concerned Veterans for America.

In remarks at a joint hearing with members of the House and Senate veterans’ committees in December, Mr. Wilkie said veterans largely liked using the department’s hospitals.

“My experience is veterans are happy with the service they get at the Department of Veterans Affairs,” he said. Veterans are not “chomping at the bit” to get services elsewhere, he said, adding, “They want to go to places where people speak the language and understand the culture.”

Health care experts say that whatever the larger effects, allowing more access to private care will prove costly. A 2016 report ordered by Congress, from a panel called the Commission on Care, analyzed the cost of sending more veterans into the community for treatment and warned that unfettered access could cost well over $100 billion each year.

A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin, center.

Tricare costs have climbed steadily, and the Tricare population is younger and healthier than the general population, while Veterans Affairs patients are generally older and sicker.

Though the rules would place some restrictions on veterans, early estimates by the Office of Management and Budget found that a Tricare-style system would cost about $60 billion each year, according to a former Veterans Affairs official who worked on the project. Congress is unlikely to approve more funding, so the costs are likely to be carved out of existing funds for veterans’ hospitals.

At the same time, Tricare has been popular among recipients — so popular that the percentage of military families using it has nearly doubled since 2001, as private insurance became more expensive, according to the Harvard lecturer Linda Bilmes.

“People will naturally gravitate toward the better deal, that’s economics,” she said. “It has meant a tremendous increase in costs for the government.”

A spokesman for the Department of Veterans Affairs, Curt Cashour, declined to comment on the specifics of the new rules.

“The Mission Act, which sailed through Congress with overwhelming bipartisan support and the strong backing of veterans service organizations, gives the V.A. secretary the authority to set access standards that provide veterans the best and most timely care possible, whether at V.A. or with community providers, and the department is committed to doing just that,” he said in an email.

Dr. Shulkin, the former secretary, shared that concern. Though he said he supported increasing the use of private health care, he favored a system that would let department doctors decide when patients were sent outside for private care.

The cost of the new rules, he said, could be higher than expected, because most veterans use a mix of private insurance, Medicare and veterans’ benefits, choosing to use the benefits that offer the best deal. Many may choose to forgo Medicare, which requires a substantial co-pay if Veterans Affairs offers private care at no charge. And if enough veterans leave the veterans’ system, he said, it could collapse.

Robert L. Wilkie, the secretary of veterans’ affairs, has repeatedly said his goal is not to privatize veterans’ health care.

One of the group’s former senior advisers, Darin Selnick, played a key role in drafting the Mission Act as a veterans’ affairs adviser at the White House’s Domestic Policy Council and is now a senior adviser to the secretary of Veterans Affairs in charge of drafting the new rules. Mr. Selnick clashed with David J. Shulkin, who was the head of the V.A. for a year under Mr. Trump and is widely viewed as being instrumental in ending Mr. Shulkin’s tenure.

Mr. Selnick declined to comment.

Critics, which include nearly all of the major veterans’ organizations, say that paying for care in the private sector would starve the 153-year-old veterans’ health care system, causing many hospitals to close.

“We don’t like it,” said Rick Weidman, executive director of Vietnam Veterans of America. “This thing was initially sold as to supplement the V.A., and some people want to try and use it to supplant.”

Members of Congress from both parties have been critical of the administration’s inconsistency and lack of details in briefings. At a hearing last month, Senator John Boozman, Republican of Arkansas, told Robert L. Wilkie, the current secretary of Veterans Affairs, that his staff had sometimes come to Capitol Hill “without their act together.”

Although the Trump administration has kept details quiet, officials inside and outside the department say the plan closely resembles the military’s insurance plan, Tricare Prime, which sets a lower bar than the Department of Veterans Affairs when it comes to getting private care.

Tricare automatically allows patients to see a private doctor if they have to travel more than 30 minutes for an appointment with a military doctor, or if they have to wait more than seven days for a routine visit or 24 hours for urgent care. Under current law, veterans qualify for private care only if they have waited 30 days, and sometimes they have to travel hundreds of miles. The administration may propose for veterans a time frame somewhere between the seven- and 30-day periods.

Mr. Wilkie has repeatedly said his goal is not to privatize veterans’ health care, but would not provide details of his proposal when asked at a hearing before Congress in December.

Access to VA Health Services Now Better Than Private Hospitals?

So, the question is with the shift of funding to the privatization of VA care is access better? Nicole Lou, contributing writer for the MedPage noted that efforts to stir up access to Veterans Affairs (VA) hospitals have cut down on wait times for new patient appointments, according to a report.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector, P<0.001), noted David Shulkin, MD, former VA secretary under President Trump, and now at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, and colleagues.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities, P<0.001). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days, P=0.01), the authors stated.

“Although the results reflect positively on the VA, we intend to continue improving wait times, the accuracy of the data captured, and the transparency of reporting information to veterans and the public,” the researchers wrote.

Their study included VA medical centers in 15 major metropolitan areas and compared them with private sector facilities. Wait times were calculated differently based on VA records and secret shopper surveys, respectively, which was a limitation of the study, the team said.

Shulkin and colleagues found that VA wait times trended toward improvement in 11 of 15 regions, whereas private medical centers had significant increases in wait times in 12 of the 15.

Prompting the scrutiny over VA hospital wait times was a 2014 report showing that at least 40 veterans died waiting for appointments at the Phoenix VA Health Care System in Arizona. Even worse, the wait times had apparently been deliberately manipulated to look better than they were.

“This incident damaged the VA’s credibility and created a public perception regarding the VA health care system’s inability to see patients in a timely manner,” Shulkin and co-authors said. “In response, the VA has worked to improve access, including primary care, mental health, and other specialty care services.”

Meanwhile, VA medical centers continue to suffer from staffing issues such as high turnover and employee vacancies in the tens of thousands.

The study authors noted a modest increase in the number of patients going to VA hospitals for the four services studied, although that number still stayed around five million per year.

Another problem with the methodology of the study was that it failed to address how easily established patients could obtain return appointments, noted an accompanying editorial by Peter Kaboli, MD, MS, of Iowa City Veterans Affairs Healthcare System, and Stephan Fihn, MD, MPH, of the University of Washington in Seattle and JAMA Network Open’s deputy editor.

Furthermore, they pointed out, a patient returning for a 6-month follow-up visit may show up in the scheduling system as having a long delay.

“As this study highlights, measuring access to healthcare remains dodgy. Even so, the seven million veterans who receive care from the VA seem able to obtain routine and urgent care in a time frame that is on par for other Americans despite increasing demand, although there are and always will be exceptions,” Kaboli and Fihn noted.

“As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate,” they continued, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.

The VA experience seems to say that privatization of healthcare delivery is the way to go with improved access to care. So, onward to discuss universal healthcare and single payer systems of health care delivery. What would they all look like and what are the strategies to develop any of these systems.